INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2023 through September 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greater Philadelphia Asian Social Service Center-Asian Outpatient Counseling Service was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and supervisor, documented in four of eight personnel records reviewed.Employee #4 was hired as a counselor on August 11, 2023. There was no documentation of an individual training plan being completed as of the date of the inspection.Employee #5 was hired as a counselor on July 20, 2023. There was no documentation of an individual training plan being completed as of the date of the inspection.Employee #6 was hired as a counselor on July 14, 2023. There was no documentation of an individual training plan being completed as of the date of the inspection.Employee #8 was hired as a counselor on August 10, 2023. There was no documentation of an individual training plan being completed as of the date of the inspection.This is a repeat citation from the October 13, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director, completed training plans for Employee #4,Employee #5, Employee #6 and Employee #8 on 10/17/23. Program Director will be sure to complete training plans for all new employees within 30 days of hire |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in three of four applicable personnel record reviewed.Employee #3 was hired as a counselor on March 16, 2022. The HIV/AIDS training and the TB/STD training were due to be completed no later than March 12, 2023. However, both trainings were not completed at the time of inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To Date:
Staff # 2 has been scheduled for DDAP STD/TB/HEP through DBHIDS Learning Hub on 11/13/2023
The program director will request a certificate of training completion to be placed in Staff # 2 personnel Chart
The program director will continue to monitor upcoming training to be sure HIV/AIDS training is completed by staff when available. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's July 2022 through June 2023 training year in two of two applicable personnel records reviewed. Employee #2 was hired as a counselor December 17, 2019. The personnel record documented 2 hours of annual training during the period reviewed. Employee #3 was hired as a counselor March 12, 2022. The personnel record documented 2 hours of annual training during the period reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To Date:
The program director, has assisted staff # 2 and staff #3 with access to DBHIDS Learning Hub to complete training related to job description
The director will provide information for ongoing training through BHTEN, Train PA and DBHIDS Learning Hub.
Counselors will be responsible for completing training and submitting completion certificates. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility safe and free from any danger to the safety and well-being of clients, employees, and visitors.There was an exposed electrical box in counselor office #2, exposed telephone wires in counselor office #1, and jumbled, exposed wires in the first floor conference room.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On September 20, 2023, the issue that caused the deficiency was successfully resolved. The Chief Operating Officer (COO) has implemented a preventive measure by conducting weekly walk-throughs to ensure that the deficiency does not reoccur in the future. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.In the second-floor bathroom, there was a faucet that was loose from the sink base.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
To Date:
This deficiency has been resolved as of 09/20/2023.
GPASS maintenance person is responsible for ensuring that all bathroom functions are working properly. The COO will conduct weekly walkthroughs of the first and second-floor bathrooms to ensure that there are no deficiencies. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters in the facility were permanently mounted or installed.There was a space heater located in the back office of the first floor. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
To Date:
This deficiency has been resolved.
All space heaters have been removed.
Staff has been informed that there are no space heaters in the facility.
The Program Director will be responsible for ensuring that no space heaters are used in the offices, by conducting regular walkthroughs of the facility. |
705.27 (1) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility failed to keep the facility free of rodents and insect infestations.At the time of the inspection, there was an unusual amount of fruit flies throughout the facility.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To Date:
On 09/25/2023, the Office Manager hired an extermination company. They will return for the next service on 10/23/2023. Additionally, the facility purchased a new deterrent for rodents and bugs. The janitor will be responsible for laying out fruit flies traps. The Office manager will be responsible for ensuring this task is completed. Further more, the back door will remain closed to ensure no other flies will come in.
COO is responsible for paying for extermination services, while the maintenance person will handle the application of deterrents. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on review of personnel records, the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies in seven of seven applicable personnel records reviewed. Employee #1 was hired as the Project Director on January 17, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.Employee #3 was hired as a counselor on March 16, 2022. There was no documentation that the emergency preparedness training was provided at the time of the inspection.Employee #4 was hired as a counselor on August 11, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.Employee #5 was hired as a counselor on July 20, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.Employee #6 was hired as a counselor on July 14, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.Employee #7 was hired as a counselor on December 12, 2022 and promoted to Clinical Lead on March 15, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.Employee #8 was hired as a counselor on July 14, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.This is a repeat citation from the October 13, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To Date:
On October 31, 2023 at 10:00 AM, the Program Director has scheduled emergency preparedness training for all staff. Staff who are unable to attend will receive alternative training on November 15, 2023 at 10:00 AM.
The Program Director will be responsible for facilitating the training.
Counselors are responsible for attending and signing off that they received the training.
As the Director, it is my responsibility to ensure that completion certificates are accurately placed in the personnel charts of our staff members. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual, written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in two of two applicable personnel records reviewed. Employee #2 was hired as a counselor December 17, 2019. The annual written staff performance evaluation dated March 28, 2023, was not signed by the employee. Employee #3 was hired as a counselor March 12, 2022. The annual written staff performance evaluation dated March 28, 2023, was not signed by the employee. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director, is responsible for adding a signature section to the annual staff report for staff members to sign after the report has been reviewed and discussed with them.
During the face-to-face meeting, the Program Director, will review and discuss the annual performance report with Staff #2 and Staff #3. A signature will be collected at that time.
Moving forward, all clinical staff will be required to sign off on annual performances. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of eight client records reviewed.Client #1 was admitted on December 28, 2022 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client, documented in the record, prior to the disclosures. Additionally, there was documentation of disclosures to a urinalysis laboratory on May 19, 2023, May 26, 2023, and June 1, 2023; however, there was no consent to release information form signed by the client, documented in the record, prior to the disclosures.Client #6 was admitted on November 14, 2022 and was discharged on July 13, 2023. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client, documented in the record, prior to the disclosures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will work with EHR to upload consent to the program in the Intake Package to ensure all clients complete consent during intake.
The director and Lead Therapist will conduct weekly chart audits to ensure consent is completed. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in four of eight client records reviewed. Client #2 was admitted on February 20, 2023 and was active at the time of the inspection. There were release of information forms to an emergency contact and a government agency that were signed and dated by the client on February 20, 2023; however, the specific information to be disclosed was not documented on either release form.Client #5 was admitted on December 12, 2022 and was discharged on March 30, 2023. There was a release of information form to a court that was signed and dated by the client on December 12, 2022; however, the specific information to be disclosed was not documented on the release form.Client #6 was admitted on November 14, 2022 and was discharged on July 13, 2023. There was a release of information form to an emergency contact that was signed and dated by the client on November 14, 2022; however, the specific information to be disclosed was not documented on the release form.Client #7 was admitted on December 14, 2022 and was discharged on March 23, 2023. There were release of information forms to an emergency contact and a funding source that were signed and dated by the client on December 14, 2022; however, the specific information to be disclosed was not documented on either release form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To Date: This deficiency has been correcte and there will be ongoing training for all staff to complete documentation in its entirety.
Weekly chart audits will be conducted by the Program Director and Lead Therapist to ensure complete documentation. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in four of eight client records reviewed. Client #2 was admitted on February 20, 2023 and was active at the time of the inspection. There was a release of information form to an emergency contact that signed and dated by the client on February 20, 2023; however, the purpose of the disclosure was not documented on the release form.Client #6 was admitted on November 14, 2022 and was discharged on July 13, 2023. There was a release of information form to an emergency contact that was signed and dated by the client on November 14, 2022; however, the purpose of the disclosure was not documented on the release form.Client #7 was admitted on December 14, 2022 and was discharged on March 23, 2023. There was a release of information form to an emergency contact that was signed and dated by the client on December 14, 2022; however, the purpose of the disclosure was not documented on the release form.Client #8 was admitted on February 2, 2023 and was discharged on June 28, 2023. There was a release of information form to an emergency contact that was signed and dated by the client on February 2, 2023; however, the purpose of the disclosure was not documented on the release form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director is responsible for ensuring consents are uploaded to EHR.
Weekly chart audits will be completed by the Director and Lead Therapist to ensure all documentation is completed accurately and comprehensively. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in three of eight client records reviewed.Client #5 was admitted on December 12, 2022 and was discharged on March 30, 2023. There were release of information forms to a court, a funding source, and a urinalysis laboratory that were signed and dated by the client on December 12, 2022; however, there was no documentation that a copy of any of the release forms were offered to the client.Client #6 was admitted on November 14, 2022 and was discharged on July 13, 2023. There were release of information forms to a probation and parole, an emergency contact, and a urinalysis laboratory that were signed and dated by the client on November 14, 2022; however, there was no documentation that a copy of any of the release forms were offered to the client.Client #7 was admitted on December 14, 2022 and was discharged on March 23, 2023. There were release of information forms to a funding source, an emergency contact, and a urinalysis laboratory that were signed and dated by the client on December 14, 2022; however, there was no documentation that a copy of any of the release forms were offered to the client.This is a repeat citation from the October 13, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To Date:
This deficiency has been resolved.
On 09/25/2023, the director met with EHR to add an option to accept or decline releases and other documentation.
Weekly chart audits will be completed by the Director and Lead Therapist to ensure compliance. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to disclose to the client the criteria for admission, treatment, completion, and discharge during the intake and admission process in eight of eight client records reviewed.In every client record reviewed, there was no documentation that the required criteria elements were reviewed with the client during the intake process.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will collaborate with the EHR team to upload the Orientation Package onto the system. This will ensure that during the intake process, counselors discuss the admission, treatment, completion, and discharge procedures with every client. To document client's acceptance of the information, a signature section will be added. Additionally, there will be a verification process to confirm whether the client has accepted a copy of the information or not.
The Director and Lead therapist will conduct weekly chart audits to ensure compliance. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to ensure that, during the intake and admission process, client orientation included familiarizing the clients with the project's hours of operation in eight of eight client records reviewed. In every client record reviewed, there was no documentation that facility staff reviewed the project's hours of operation with the client during the orientation period.This is a repeat citation from the October 13, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Directo will submit an orientation package to the EHR and include the project's hours of operation.
The Director and Lead Therapist will perform weekly audits of the charts to ensure compliance. Any mistakes or errors will be identified and corrected promptly to maintain accuracy and consistency in record-keeping. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to ensure that, during the intake and admission process, client orientation included familiarizing the clients with the project's fee schedule in eight of eight client records reviewed.In every client record reviewed, there was no documentation that facility staff reviewed the project's fee schedule with the client during the orientation period.This is a repeat citation from the October 13, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To Date:
This deficiency has been resolved
On 06/06/2023, the Program Director met with EHR Personnel to add a pay schedule to the system. This was completed to ensure that intake staff discussed, reviewed, and obtained client signatures.
The Director and Lead therapist will conduct weekly audits of the charts to ensure their accuracy and compliance. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to ensure that, during the intake and admission process, client orientation included familiarizing the clients with the services provided in eight of eight client records reviewed. In every client record reviewed, there was no documentation that facility staff reviewed the services provided by the project with the client during the orientation period.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will meet with EHR personnel to add an orientation package that includes project services.
After implementation, the Director and Lead Therapist will ensure accuracy through weekly chart audits. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment on the individual treatment and rehabilitation plan in five of eight client records reviewed.Client #1 was admitted on December 28, 2022 and was active at time of inspection. The individual treatment and rehabilitation plan was completed on February 27, 2023; however, the plan did not include the frequency of treatment and rehabilitation services. Client #2 was admitted on February 20, 2023 and was active at time of inspection. The individual treatment and rehabilitation plan was completed on April 14, 2023; however, the plan did not include the frequency of treatment and rehabilitation services. Client #3 was admitted on April 14, 2023 and was discharged on August 15, 2023. The individual treatment and rehabilitation plan was completed on May 9, 2023; however, the plan did not include the frequency of treatment and rehabilitation services. Client #4 was admitted on April 5, 2023 and was active at time of inspection. The individual treatment and rehabilitation plan was completed on May 4, 2023; however, the plan did not include the frequency of treatment and rehabilitation services. Client #6 was admitted on November 14, 2022 and was discharged on July 13, 2023. The individual treatment and rehabilitation plan was completed on December 11, 2022; however, the plan did not include the type and frequency of treatment and rehabilitation services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/05/2023, the Program led a Group Supervision session with staff, providing guidance on documenting initial treatment to reflect the frequency of treatment.
Director and Lead Therapist are responsible for weekly chart audits to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of eight client records reviewed.Client #1 was admitted on December 28, 2022 and was active at the time of inspection. A treatment plan update was completed on May 29, 2023, and the next update was due no later than July 29, 2023; however, the update was completed on August 7, 2023.Client #2 was admitted on February 20, 2023 and was active at the time of inspection. A treatment plan update was completed on May 11, 2023, and the next update was due no later than July 11, 2023; however, the update was completed on August 17, 2023Client #6 was admitted on November 14, 2022 and was discharged on July 13, 2023. The individual treatment and rehabilitation plan was completed on December 11, 2022, and the first update was due no later than February 11, 2023; however, the update was completed on February 21, 2023. Client #8 was admitted on February 2, 2023 and was discharged on June 28, 2023. The individual treatment and rehabilitation plan was completed on March 7, 2023, and the first update was due no later than May 7, 2023; however, the update was completed on May 29, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/05/2023, the Program Director met with clinical staff to discuss tardiness in treatment plans. The staff will provide the Director with a plan to stay in compliance with the completion of treatment plans by 10/31/2023.
Director and Lead Therapist are responsible for weekly chart audits to ensure compliance. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record, which is to include documenting follow-up information, in two of two applicable client records reviewed.Client #3 was admitted on April 14, 2023 and was discharged on August 15, 2023. There was no documentation of follow-up information in the record at the time of the inspection.Client #5 was admitted on December 12, 2022 and was discharged on March 30, 2023. There was no documentation of follow-up information in the record at the time of the inspection.This is a repeat citation from the October 13, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has recently hired a designated staff to complete this function. Director Met with EHR personnel on 07/25/2023 to upload a 30-90 day follow-up form.
After staff arrives, the Lead Therapist will be responsible for reviewing the follow-up list and EHR follow-up form for accuracy. |